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ANTHEM BI,iTE CROSS AND Bi.LTE SHIELD <br />, FRO0' 111ER lriAll\TE1RAlil.E FORM <br />Anffiem. 0. Vc? <br />Seetimn D. PRACTICE ADDRESS. **I2EQUiRED x* Plote: Ijehanging adclress note PIQEEYdUUS address here. <br />?OTNIPI.ETE REMIT ADDRESS IFDIFPEREr'T FRONI PRAC1'IC'E ADDRESS <br />Practice Address 0 $, Q. IYl . C E NT E 12 R o R D Remit Address (required) <br /> <br />?ity A" Ei- fl v ILL <br />State D N ZiP N I 113 I <br />Cin' S7R 6 E T S t3 o R o <br />State o ff <br />ZiP y ya y/ <br />Counry u` R N 0 G A County poR r/9 c e <br />Phone Number (patients can caIl) <br />(_tyo) yLl - if,y? Fax Number <br />cyyv) yb? - U?..? .2 Remit Phone Number <br />(:330) ka4, -yqs"c) Remit Fax Number <br />(33U1 !o??(o-?S?.?v <br />Email Address Group NPI 1-73 0 3 a R S 94 <br />Medicare ?'rroup Number Medicare Individual Number <br />9 3 g 3 Y3 i Medicaid Group Number Niedicaid Individual Number <br />List site within Anthem's directory/ web pages? Yes ? No ? Access to Public Transportation? <br />I Yes ? <br />No ? <br />Handicap Accessible? yes El No [I Eveni.ng Hours? Yes ? No ? <br />Weekend Hours? Yes ? No ? Days Office is Open: ? M ? T ? W? T? F <br />Sec6oa E. ADDRESS IlNF(?RMATION CHAiNGE Note: I chan-in adc€ress, lace NER'address here_ <br />Pracrice Address Remit Address (required) ' <br />City Staxe Zip City State Zip <br />Counry Counry <br />Phone Number (patients can call) <br />?) - Fax Number <br />?-) - Remit Phone Number <br />?-? - Remit Fax Number <br />C-) - <br />Email Address Group NPI <br />Medicare Group 1Vumber Medicare Individual Number Medicaid Group Number Medicaid Individual Number <br />List site within Anthem's directory/ web pages? Yes ? No ? Access to Public Transportation? Yes ? No ? <br />andicap Accessible? yes E] No E] Evening Hours? Yes ? No ? <br />Jeekend Hours? Yes ? No ? Days Office is Open: [:1 M ? T ? W? T? F <br />Seetioa F. ADDI7'IOiNAL OFFICE LOCATION (S) Usa Separate Piece of Paper for rSa3ditioaat Practice SitPS. <br />COIVIPLETE REMIT ADDRESS (ES) IF DEUERE??iT FROi-A PRAC'FICE AD73RESS (ES) ' <br />SECOND PracYice Name: <br />Practice Address Remit Address (required) , <br />City State Zip Ciry State Zip <br />Counry County <br />Phone Number (patients can call) Fax Number Remit Phone Number Remit Fax Number <br />Email Address Group NPI <br />Medicaze Group Number Medicaze Individual Number Medicaid Group Number Medicaid Individual Number <br />List site within Anthem's directory/ web pages? Yes ? No ? Access to Public Transportarion? Yes ? No ? <br />Handicap Accessible? yes [I No ? Evening Hours? Yes ? No ? <br />Weekend Hours? Yes ? No ? Days Office is Open: 0 M ? T ? W? T? F <br />ec e->' <br />ten by HMO?y Ftismun, <br />? <br />i ) uMefwrites or <br />)S <br />macks of fhe SIUe